Welcome

Getting Care for TRICARE Prime Beneficiaries

TRICARE Prime programs (including TRICARE Prime Remote and TRICARE Young Adult Prime) are managed care programs. When using one of these plans:

  • You receive routine (primary) health care from your primary care manager (PCM). If your PCM is unavailable for routine care or you require specialty care, he or she will refer you to another health care provider. Check the prior authorization and referral requirements to determine if an approval is needed for care.
  • You are guaranteed access to care within specific time frames.

Learn about benefits on TRICARE's Covered Services page.

For cost-share and deductible information, visit TRICARE's Costs & Fees page.

Types of Care

Routine Care

Routine care includes general office visits for the treatment of symptoms, chronic or acute illnesses and diseases, and follow-up care for an ongoing medical condition. You will receive most of your routine or primary care from your PCM.

You do not need a referral to visit your PCM. If your PCM is unable to provide the care needed, he or she will refer you to another provider. If you receive any routine care from another provider without a referral from your PCM and approval from Health Net Federal Services, LLC (HNFS), you are chosing the Point of Service (POS) option, which has higher out-of-pocket costs. The POS option does not apply to active duty service members, who may be responsible for the entire cost of their care.

Preventive Care

Preventive care is a periodic health screening or assessment and is not directly related to a specific illness, injury or set of symptoms. You will receive most of your preventive care from your PCM.

You do not need a referral to visit your PCM or to obtain preventive care from a network provider. If your PCM is unable to provide the care needed or a network provider is not available, your PCM will refer you to another provider. If you receive any care from a non-network provider without a referral from your PCM and approval from HNFS, you are chosing the POS option, which has higher out-of-pocket costs. The POS option does not apply to active duty service members, who may be responsible for the entire cost of their care.

Learn more about preventive care on TRICARE's Preventive Care page.

Specialty Care

There are times when you will need to see a specialist for a diagnosis or treatment your PCM cannot provide. Your PCM will provide referrals to access services from specialty providers and will coordinate the referral request with HNFS, if necessary. If you do not have an assigned network PCM, you or your primary care provider must coordinate specialty care referrals with HNFS.

If you receive specialty care without a referral from your PCM and approval from HNFS, you are chosing the POS option, which has higher out-of-pocket costs. The POS option does not apply to active duty service members, who may be responsible for the entire cost of their care.

Urgent or Emergent Care

For information on seeking emergency or urgent care, please refer to our emergency care and urgent care pages.

Locating a Provider

Here are resources for locating authorized providers:

Military hospitals and clinics – As a TRICARE beneficiary, you have access to some of the best medical care in the country. You can get care at military hospitals and clinics on a space available basis. If you live near a military hospital or clinic, it should be your first source for treatment, especially for specialty care when available. There is no cost for outpatient services and inpatient services only have a small copayment per day. Find a military hospital or clinic by using TRICARE’s Military Hospital and Clinic Locator.

TRICARE network providers – When seeking civilian care, TRICARE Prime beneficiaries are required to use TRICARE network providers when available. Search our Network Provider Directory. If a network provider is not available within access standards, you will be referred to a non-network provider.

Non-network participating providers – These providers submit claims to TRICARE and agree to accept the TRICARE-allowed amount as payment in full minus deductibles, copayments and cost-shares. If you receive any care from a non-network provider without a referral from your PCM and approval from HNFS, you are chosing the POS option, which has higher out-of-pocket costs. The POS option does not apply to active duty service members, who may be responsible for the entire cost of their care.

Non-network providers who do not accept assignment (nonparticipating) – These providers do not bill TRICARE. You may be required to pay upfront for services in full and submit a claim to TRICARE for reimbursement. Nonparticipating providers may bill you up to an additional 15 percent above the TRICARE-allowed amount. However, if you have an approval from HNFS, TRICARE will cover the 15 percent. If you receive any care from a non-network provider without a referral from your PCM and approval from HNFS, you are chosing the POS option, which has higher out-of-pocket costs. The POS option does not apply to active duty service members, who may be responsible for the entire cost of their care.

Can't Locate a TRICARE Provider?

If a provider does not accept TRICARE patients, you can encourage him or her to become a TRICARE provider. Ask your provider to visit www.tricare-west.com.